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Application <br />- FOR - <br />CerUf icate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd, South Send, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone 574-Z5-97% - Fax: 574235-9578 - 'Email:SWCHPC®co.stjowphin.us <br />Website: http:Jlwwwstjowphcountynnd=&CD`mf sjchp/mdex.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTIINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received_7_14d..206 Application Number d �►D '% - !!� J <br />Past Reviews: (DareoltAst ttevtem) ! -t 00 7 [] NO <br />Staff Approval authorized by. Title: <br />Historic Commission Review Date: j `� . oYoo7 <br />Qv 116cal Landmark Focal Historic District (Name) <br />[] National Landmark [gWational Register District (Name) <br />Certificate of Appropriateness: <br />[� Denied E] Tkbled [-] Sent To Committee Approved and Issued <br />• DATE <br />Address of Property for proposed work: `Tl 0 pmr c, Ave <br />Street Nu r and Street Name <br />7 LE <br />Name of Property Owner(s): (Prean Print) C�� >� Na <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Current Use of Building: <br />Type of Building Construction: <br />7/0 rvtrL t4r�. <br />/Zi(-`FFAe7) Gjt)i T -LF_ <br />t4cliu, gervicir <br />NWC".q' - KI Phone: pl 74- '220 44 -7S - <br />(Single Family — multi-pa?"itY commm*1 <br />4-7S-(SingleFamily—Multi-Family—Commercial Government—Industrial—Vacant—etc.) <br />WCr3t:^Frtlfl�rl�` <br />(Wood From — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: [] In-kind n Landscape [] New [] Replacement (not in -End) (] Demolition <br />(mane than am box may be chwked) <br />Description of Proposed Work: T(9 -(AX 1 L4CA4 Vi, -t N 01 A C 48-% ft -t W iA,% fV,0 k i <br />Pll nA VXK4,irk r0,*44- dal bie. gu r do1A6 r --;line t <br />U&�,t to"r c r; x Anw, <br />Owner/cvntami: Fax .1 74 At .�"S�.S- e-mail tA4E c (,- 9 n PI . E �" <br />(This o1rur WX correspond om only one designee) <br />and/orX <br />-- APPLICA1WON REQUIREMENTS ARE LISTED ON REVERSE SIDE -- <br />